Intrapartum Complications, Emergencies, and Procedures

Induction indications

Post-term gestation, maternal/Fetal comorbidities or concerns, elective induction at term

Risks associated with induction

Tachysystole, failed IOL (Induction of Labor), increased risk of cesarean deliveries with primary inductions (especially with unfavorable conditions)

Induction and augmentation management

Same assessment/monitoring/interventions as spontaneously laboring patient but known higher risks (C-EFM highly probable)

Augmentation indications

Insufficient uterine activity/uterine dysfunction, prolonged ROM (controversial), overall goal is to strengthen and regulate uterine contractions and/or shorten length of labor

Augmentation contraindications

Prior classical uterine scar, placental abnormalities, malpresentation of fetus, UCP, active HSV, pelvic abnormalities

Augmentation risks

Tachysystole and/or possibility of fetal distress

Alternative/complementary augmentation methods

Castor oil, enemas, sexual intercourse, nipple stimulation

Mechanical cervical ripening

Cervical dilators, good option for little to no cervical effacement, good option if pharmacological means are contraindicated, risk of increased infection and PROM, in place 6-12 hours on average

Cervical dilators

Foley bulb, Cook catheter, Dilapan

Pharmacological cervical ripening

Medications, very effective, risks include tachysystole, can induce labor, and possibly create fetal distress, not appropriate for TOLAC/VBAC patients

Sweeping/stripping of membranes

Digital separation of chorionic membrane from the wall of the cervix and lower uterine segment during SVE to stimulate labor, uncomfortable but short duration, releases prostaglandins, only completed at term, some dilation required, overall increases the likelihood of spontaneous labor onset, decreases formal IOL rate, (induction assistance)

Amniotomy

Artificial rupture of membranes (AROM), amnihook utilized by HCP, increases prostaglandins and pressure from fetal presenting part on cervix, consider risk vs. benefit, fetal station, increased risk of infection correlates with time after ROM occurs, monitor FHR (induction or augmentation)

Amnioinfusion

Warm, sterile normal saline or LR solution is introduced into uterus through an IUPC, used to relieve cord compression or thin meconium in fluid

Oxytocin/pitocin

Most common induction agent, used alone or in combo with other methods, onset is 3-5 minutes after IV infusion, high risk med in intrapartum period, if labor is established = no evidence to support use of, risks include tachysystole leading to fetal distress, failed IOL, increased risk of uterine rupture if history of scar tissue present, oxytocin/pitocin use in IP always warrants continuous EFM

Precipitous labor

Rapid labor and birth, < 3 hours from onset, occurs in roughly 3% of deliveries

Precipitous labor risks

Increased anxiety and pain, increased risk of PPH due to uterine atony or lacerations, fetal risk of hypoxia

Precipitous labor risk factors

Grand multiparity, Hx of precip labor

Potential causes of prolonged first stage

Hypertonic uterine dysfunction, hypotonic uterine dysfunction, arrest of labor diagnosis cannot be made prior to reaching 6cm dilation

Hypertonic uterine dysfunction

Uncoordinated uterine activity

Hypotonic uterine dysfunction

Inadequate contraction strength

Potential causes of prolonged second stage

Epidural anesthesia, obesity, OP position “sunny side up”, maternal exhaustion leading to ineffective pushing

Cephalopelvic disproportion

Small or abnormal pelvis shape, large baby, delayed descent of fetal head

Malpresentation and external cephalic version

Breech presentations not routinely delivered via vaginal route (risks outweigh benefits in many circumstances)

External cephalic version (ECV)

Turning of the fetus using external manipulation by HCP, abdominal (external) or intrauterine (internal) manipulation

Criteria of ECV

Breech, shoulder, transverse, 36weeks gestation or greater, NST prior is reactive, breech is not engaged

Contraindications of ECV

Hx of placental abruption, severe preeclampsia, nonreassuring fetal status

ECV risk of complications

ROM, leading to UCP, labor, placental abruption, need for c/s d/t NRFHR, stillbirth/fetal hemorrhage, pain/discomfort

Vacuum-assisted delivery

Applied to fetal head with negative pressure, nurse may be asked to pump device to a specified pressure, while MD applies and manipulates, most policies say 3 strikes and you’re out (head to OR), “pop offs” are warning sign (update patient), utilized for >34 weeks gestation only, unsuccessful = cesarean delivery

Vacuum-assisted delivery risks

Lacerations, PPH, bladder trauma, cephalohematoma (NB)

Forceps-assisted delivery

Sides, called blades, placed over parietal bones, sides locked together with downward traction, must have fetal head engaged, ROM, vertex presentation (some presentations are conducive; face/brow for instance may not fit), utilized for >34 weeks gestation only, fewer providers skilled at/comfortable with than vacuum (less occurrence)

Forceps-assisted delivery risks

Vaginal and cervical lacerations (6x increase in 3rd and 4th degree), PPH, Perineal hematoma, bladder trauma, facial bruising (NB), facial lacerations/nerve palsy (NB), corneal abrasions/ocular trauma (NB)

Post term pregnancies

>42 w gestation, at 41 w risk of neonatal and post-neonatal death increases significantly highly due to placental function decrease, antenatal surveillance and IOL at 41 weeks common practice, dating is important

Post term pregnancies risks

Macrosomia (increases OVD risk), C/S, shoulder dystocia, neonatal seizures, meconium aspiration syndrome

Meconium stained fluid

10-20% of deliveries, meconium is passed by fetus and enters amniotic fluid, highly correlated with fetal hypoxic stress, aspiration can result in respiratory distress after delivery, suctioning no longer considered EBP during IP/delivery process

Meconium stained fluid interventions

Note color/ consistency, if there’s time in labor and fetus is stable can do IUPC and amnioinfusion to thin meconium, check policy for when to use SCN/NICU, if infant is vigorous/crying, great, no need to intubate or deep suction

Multiple gestations

Delivery method dependent on factors including number of fetuses, position and presentation, fetal weight, type of multiples, vaginal deliveries possible depending on factors, some patients choose c/s as alternative after risk vs benefit analysis even if, monitoring more challenging with multiples (not impossible)

Multiple gestations risks

Preterm birth, preeclampsia, and PPH

Stillbirth/fetal demise

Fetal death after 20 weeks gestation, 1 in 160 deliveries in the US (23,600 annually)

Stillbirth/fetal demise method/timing of delivery

Diagnosis depends on GA, OB history, maternal preference, <28 weeks = vaginal misoprostol induction, >28 weeks = delivery/IOL managed according to typical protocols, C/S delivery reserved for unusual circumstances

Stillbirth/fetal demise risk factors

Black race, nulliparity, AMA, obesity, preexisting diabetes, CHTN, smoking, alcohol use, reproductive technology induced pregnancy, multiple gestation, male sex fetus, unmarried status, and previous hx of loss

Stillbirth/fetal demise causes by frequency

Unspecified cause (over half), complications of placenta/cord/membranes, congenital/chromosomal abnormalities, maternal conditions unrelated to pregnancy

Post stillbirth/fetal demise delivery interventions

Use grief counselor/ pastoral care, have parents see, touch and hold baby, encourage parents to name child, do footprints, lots of photos, take a lock of hair, encourage some kind of service to commemorate their infant

Intraamniotic infection (chorio)

Increased risk with PROM, Maternal fever with one or more of: fetal tachycardia, maternal WBC count >15,000 (absence of corticosteroids), furulent fluid from the cervical os, cloudy/yellow/thick discharge from the cervical os, bacteria in amniotic fluid/placental pathology

Management/identification of IAI/chorio

Temp checks q2 after ROM in labor (fever >100.4˚F/37.8˚C), assessment of amniotic fluid, limit vaginal exams (maintain sterile technique, uterine tenderness, hypotension, diaphoresis, close monitoring of FHR for increasing baseline, intrapartum and pp antibiotic therapy, close monitoring of newborn for s/s of infection, may receive prophylactic abx therapy

Maternal obesity risks

Prolonged labor, fetal macrosomia, shoulder dystocia, operative vaginal births and cesarean deliveries, difficult placement of anesthesia, poor outcomes with TOLAC

CHTN risks

Preeclampsia/eclampsia

Preexisiting (poorly managed) diabetes risks

Congenital malformations, miscarriage and stillbirth

Shoulder dystocia

Difficulty in delivery of shoulders secondary to anterior shoulder becoming impacted on the pelvic rim, delayed restitution/need for facilitated restitution (spontaneous alignment of fetal head with body), inability to deliver anterior shoulder with usual traction effort, 1-3% of all births

Shoulder dystocia risk factors

GDM, hx of macrosomic infants, maternal obesity, increased weight gain in pregnancy, small/contracted pelvis, hx of shoulder dystocia, estimated fetal weight one pound larger than last infant

Turtle sign

Immediate retraction of fetal head against the perineum after extension

Shoulder dystocia maternal complications

Extensive lacerations, bladder injury, PPH, traumatic birth experience/anxiety (very stressful)

Shoulder dystocia fetal complications

Fractured clavicle, brachial plexus injury, hypoxia/anoxia, fetal death

Shoulder dystocia interventions

Pull together team, immediately page HCP STAT (if not present), notify anesthesia/neonatal teams, stay calm, inform patient and family of what’s happening, have steps memorized (while you’re performing one step, think ahead to the next trick up your sleeve)

Shoulder dystocia nurse interventions

McRoberts, knee chest position (Gaskins), straight cath, suprapubic Pressure (not fundal) when instructed by provider

Shoulder dystocia provider interventions

Episiotomy, Wood’s Screw, deliver posterior arm, break anterior clavicle, Zavanelli (head pushed back/c/s performed, not ideal)

Umbilical cord prolapse

Cord lies below or beside presenting part/can compromise blood flow to infant, happens when presenting part does not fill pelvic inlet (floating head with ROM or malpresentations), 1 in 400 pregnancies, 24-35% occur at time of AROM/SROM

Signs and symptoms of uterine cord prolapse

Umbilical cord visible or felt, change in fetal heart rate after ROM (whether spontaneous or artificial)

Umbilical cord prolapse risk factors

Malpresentation, preterm gestation, IUGR or SGA, unengaged fetal presenting part, polyhydramnios, multiple gestation

Occult cord prolapse

Cord dropping alongside the baby, but may not be seen in advance

Overt cord prolapse

Cord coming out before baby’s head can come out

Umbilical cord prolapse interventions

Elevate presenting part (don’t remove hand!), knee-chest position/Trendelenburg, call for help, get HCP in-route, O2 at 10 L/min, IVF bolus, FHR monitoring, consider terbutaline/tocolytics, prepare for c/s (high possibility will need general anesthesia)

Vasa previa

Abnormal fetal blood vessels that run through fetal membranes over/near cervical os, unprotected by placenta or umbilical cord/Wharton’s jelly casing, diagnosed via US or with ROM including V

Vasa previa rupture risk factors

Low lying placenta or placenta previa, IVF, multiple gestations

Vasa previa rupture risks

Fetal asphyxia, blood loss

Vasa previa diagnosed during AP

Scheduled for c/s delivery during late preterm (prior to onset of labor or ROM) = neonatal survival 95%

Vasa previa diagnosed after rupture

Catastrophic blood loss can occur; risk for maternal and fetal mortality especially in outpatient setting

Uterine rupture

Laceration of uterine wall, tears may extend to uterine vessels which leads to hemorrhage, cause of maternal/ fetal death, may be incomplete/complete based on layers of uterus involved, 0.07% incidence overall, 0.7% with TOLAC (10x increase)

Complete uterine rupture

Direct opening from uterine cavity to peritoneal cavity

Incomplete uterine rupture

Rupture to peritoneum lining, but not through uterus

Uterine rupture dehiscence

Partial separation of old uterine scar

Uterine rupture signs and symptoms

Mom reports that something “gives way”, sharp pain in lower abdomen-pain may radiate, is felt continuously, contractions cease, mom may become anxious, may have tachycardia, become shocky, blood loss occurs, can feel fetal parts close to fingers on external exam, FHR bradycardia/absent

Uterine rupture management

O2, mobilize team, type and cross, 2 large bore IVs, get moving quickly

Amniotic fluid embolism (AFE) (anaphylactoid syndrome)

Small tear in amnion or chorion, chance for a small amount of amniotic fluid to leak into chorionic plate and enter maternal system, rare (0.0012-0.0077%) but high mortality rate (30-50%), survivors have 50% chance of developing DIC, nearly all require massive transfusion, often have permanent neurological injury, unpreventable, and unpredictable, presents during labor or immediately following birth

AFE signs and symptoms

Dyspnea, hypotension, cyanosis, cardiac arrest (cardiorespiratory collapse), hemorrhagic shock

AFE risk factors

Difficult/rapid labor, advanced maternal age, c/s, instrumental delivery, placenta previa or abruption, grand multiparity, cervical lacerations, NRFHT, eclampsia, IOL, African American, maternal cerebrovascular disorders or cardiac disease

AFE nursing interventions

Administer O2, establish multiple IV lines, if resp/cardiac arrest occurs perform CPR, call anesthesiologist immediately, medical interventions are supportive